For years, constant voices in his head led him to believe he was the target of a sinister plot, and pushed him to abuse alcohol and crack cocaine.
"I really needed something to calm almost a beast inside of me," said Raymond Stuart Reed, 45, a Relay resident who has battled chronic paranoid schizophrenia and underlying depression since he was about 15 years old. "I'd be walking, almost running, to the liquor store on a daily basis."
In the three decades since he first began noticing the signs of his mental illness, which can distort his reality, Reed has bounced from one place to the next, trying to remain one step ahead of homelessness and one step ahead of the addictions caused by his attempts to cope with his illness.
There have been stints in hospital psychiatric units, in shelters and in a rental apartment that turned out to be a "crack den," he said.
There have been lots of couches, many left in the ashes of burned bridges with family members and friends.
For the past five years, Reed has mostly lived with his girlfriend, Mary Atwater, in her Relay home. He is now on a daily drug regimen — five drugs in all, including insulin for his Type I diabetes — that has allowed him to stabilize his condition and stop using drugs. He makes ends meet with monthly disability checks and money left to him by his father.
Still, Reed feels he has been "struggling and sinking for the longest time," he said, largely because of his difficulty finding long-term, affordable housing.
He's not alone.
Across the county, and throughout the Baltimore region, there is a severe shortage of affordable housing for those with psychiatric conditions, especially those with medical and psychosocial needs that can't be met in traditional living situations, according to mental health advocates and officials.
"It's bleak," said Sendy Rommel, president and CEO of Prologue Inc., an organization that provides housing support for people with mental illnesses in Baltimore and Carroll counties.
According to one 2010 national study, the Baltimore region is among the 30 least affordable rental markets in the country for those receiving disability support, and Maryland is one of the least affordable states. Alternative housing options — whether through government subsidies and vouchers or through non-profit support — are few and far between, advocates said.
The shortage has contributed to crammed psychiatric units at hospitals throughout the state, years-long waiting lists at local residential rehabilitation programs (RRP) and homelessness within the community, they said.
"One of the challenges for folks is the availability of housing alternatives," said Robert Blankfeld, head of the county's Core Service Agency, the local authority responsible for mental health services.
Backlogs and homelessness
A key factor in the housing shortage is the half-century evolution of thinking on treatment and housing that has led to a shift away from state psychiatric institutions.
Before that evolution, state institutions served as the de facto destination for thousands of patients, who were often sent to the institutions indefinitely.
Today, there is broad consensus that state institutions are not the best option for most patients, and an intense focus on rehabilitation and reintroduction of patients into the community has contributed over decades to a drastic decrease in the number of patients at state psychiatric hospitals and a proliferation of community-based treatment and housing alternatives.
Thirty years ago, about 70 percent of state mental health funding went to state institutions and 30 percent went to community programs, said Brian Hepburn, executive director of the Maryland Hygiene Administration, which oversees the state's public mental health system (PMHS).
Today, those numbers are reversed. Still, there aren't enough housing options available for the mentally ill, who, advocates say, shouldn't be institutionalized but can't pay rent on their own.
In Baltimore County, more than 220 people are waiting for one of the county's 321 filled RRP spots to open. Some of whom are likely to wait for a year or longer before receiving a placement, Blankfeld said.
That's especially true for those currently living in the community but seeking an elevated level of care, as they are last in a priority system that places patients from state institutions, general hospital units and hospital shelters before them, regardless of time spent on the waiting list.
Once patients get into an RRP — which is a full-time, intensive treatment option — they are likely to stay longer than their condition may require because other housing options are so scant and because some forms of disability support are cut off with departure, leading to a bottleneck coming out of the programs, Blankfeld and others said.
"We're looking at a system where you've got limited resources and where you've got a demand that exceeds the resources," said Blankfeld, whose office facilitates RRP placements.
"We frequently get the call or run into the situation where you have an aging adult parent who's been taking care of an aging adult child in the home setting, and that situation has gone along for various numbers of years, at various levels of stability. And it's been working out, but now with the parent aging, they aren't able to care for their adult child," Blankfeld said.
In those situations, there is often a "recognition that the status quo arrangement may not endure" among service providers, but no RRP spot to offer, he said.
While many programs offer treatment and therapy services without housing, patients in those programs often start to regress because of housing instability, advocates said.
For those with mental illnesses, that instability often undercuts hard-won progress with their conditions, and creates obstacles to taking medicine on time and avoiding situations that trigger particularly intense episodes of illness, advocates said.
According to Sue Bull, Baltimore County's homeless services coordinator, a January survey of 881 homeless adults in the county's shelters and on the streets found that 20 percent had a mental illness, and 38 percent had a "disabling condition."
Budget flat as population climbs
State funding for mental health services has routinely been put on the chopping block in recent years as legislators fight to control Maryland's deficit, forcing advocates to wage yearly lobbying efforts inAnnapolis.
They have had some successes, most recently when Gov. Martin O'Malleyprovided a supplemental appropriation of funding in April to offset previous cuts to community mental health reimbursement rates for fiscal year 2012, said Herbert Cromwell, executive director of the Community Behavioral Health Association of Maryland, which is based in Catonsville and represents community-based treatment and housing providers.
The problem is that flat or even slightly higher levels of funding can't possibly meet the needs of a mentally ill population growing at a much faster rate, Cromwell said.
According to statistics provided by Cromwell, the PMHS is projected to serve 139,000 people in fiscal year 2012, up from 99,000 people served in fiscal year 2008.
"The problem is that the demand for services, particularly community services, far exceeds budget capacity year after year," Cromwell said.
Meanwhile, the state has substantially reduced its number of state psychiatric beds since 2003, and the Department of Health and Mental Hygiene is also currently in the process of procuring a new study of the short- and long-term patient capacity needs at its five remaining psychiatric hospitals, including Spring Grove Hospital Center in Catonsville.
The study, required by the legislature, likely won't result in additional capacity changes for years to come, said Betsy Barnard, director of the health department's office of capital planning, budgeting and engineering services.
But mental health advocates are worried regardless.
They agree the role of state institutions should decline, but said the state has a record of downsizing state psychiatric capacity while keeping funding for community-based alternatives flat.
"The reason that the state wants to close the beds is to save money, and in a bad economic situation, there's always the risk and the reality that the state will have that money revert to the general fund," said Laura Cain, an attorney with the Maryland Disability Law Center.
The state also issued in 2000 what amounted to a moratorium on new RRP beds in the state, despite the fact that providers would be eager to create more beds if allowed, Cromwell said.
Hepburn, of MHA, did not respond to multiple requests for comment on that unofficial moratorium.
He did say cuts to state psychiatric beds since 2003 have resulted in more community-based housing options, including 12 new RRP positions opened with the closure of the Upper Shore Community Health Center in Chestertown last year.
A total of 4,000 people received RRP services in the state in 2010, compared to 2,600 in 2003, he said.
Still, it is true that funding cuts at state institutions don't necessarily amount to dollar-for-dollar increases for community programs, he said.
In 2009, the National Alliance on Mental Illness compiled a report called "Grading the States," in which it evaluated mental health services across the country and gave each state a letter grade between "A" and "F."
No state received an "A," and the nation as a whole received a "D." Maryland was one of only six states to receive a "B," making it one of the country's best in dealing with mental illness, according to the alliance's evaluations.
But when affordability of housing for people with disabilities is considered alone, Maryland drops from the top of the class to the bottom, according to the national "Priced Out in 2010" study conducted by the Technical Assistance Collaborative and the Consortium for Citizens with Disabilities Housing Task Force.
The study directly compares federal Supplemental Security Income payments, which are received by people with severe mental and physical disabilities and used for housing, to "fair market rents" for one-bedroom apartments in markets around the country, as calculated by the U.S. Department of Housing and Urban Development (HUD).
Only Hawaii andWashington, D.C., were less affordable than Maryland, where a one-bedroom apartment costs 164 percent of a person's $674 monthly SSI payment in 2010, the study found.
Among all HUD-defined rental markets in the country, only 30 had average rents for one-bedroom apartments that cost more than 150 percent of a person's monthly SSI payment. In the "Baltimore-Towson" market, which includes Catonsville and Arbutus, the average rent was 156 percent of SSI.
Overall, the state has a long way to go in shaping a mental health system and housing plan to meet the needs of the mentally ill population, said advocates and mentally ill residents.
Namely, there is a need for independent living units subsidized in some way that provide "wrap-around" treatment and therapy services while allowing tenants to retain their independence and privacy, advocates said.
Reed agreed that independent living quarters are needed and desired by people with mental illnesses like his.
While he greatly appreciated the support he's received in the past from the Grassroots Crisis Intervention Center in Columbia, life in a shelter is difficult, he said.
"You feel like you're being trampled on by people coming and going," he said. "You just felt like you were on display."
Through the years, the search for housing has made him feel like "a chicken with my head cut off," he said — a feeling made worse by the misunderstanding and stigma attached to his illness, especially among bosses and co-workers at the various jobs he's tried to hold down.
"I'm not in a wheelchair, they see 10 fingers, 10 toes, and they think I can work," he said. "But the psychosocial aspects have been too much."
His medicine is sedating. If he works too many hours, his disability income may be cut off. And his less-than-clean criminal record doesn't help.
"I'm struggling to get by," he said. "I've tried to do odd jobs, but I'm not making much headway."